The use of transjugular intrahepatic portosystemic stent shunt in the management of acute oesophageal variceal haemorrhage

Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes

Acute variceal bleeding is a life-threatening condition that requires a multidisciplinary approach for effective therapy. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This procedure involves establishment of a direct pathway between the hepatic veins and the portal veins to decompress the portal venous hypertension that is the source of the patient's bleeding. The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%-50% in the emergency setting, but has an effectiveness greater than 90% in controlling bleeding from gastro-esophageal varices. This review focuses on the role of TIPS in the setting of variceal bleeding, with emphasis on current indications and techniques for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolization of varices.

Comparison of percutaneous transhepatic variceal embolization (PTVE) followed by partial splenic embolization versus PTVE alone for the treatment of acute esophagogastric variceal massive hemorrhage

PURPOSE

To compare the efficacy of percutaneous transhepatic variceal embolization (PTVE) followed by partial splenic embolization (PSE) with that of PTVE alone for the treatment of acute massive hemorrhage of esophagogastric varices in patients with cirrhosis unable to undergo alternative procedures.

MATERIALS AND METHODS

Sixty-five patients with acute variceal massive hemorrhage were retrospectively studied, including 31 who underwent PTVE/PSE and 34 who underwent PTVE and refused PSE. Recurrent bleeding rate, survival rate, postoperative complications, number of days of hospitalization after PTVE, and outcome were evaluated. Peripheral blood cell counts and hemoglobin levels before and at 1 week and 6, 12, and 24 months after intervention were analyzed.

RESULTS

Cumulative recurrent bleeding rates at 6, 12, and 24 months after intervention in the PTVE/PSE group were 3.2%, 6.7%, and 13.3%, compared with 20.6%, 36.7%, and 53.6%, respectively, in the PTVE group; the difference at each time point was statistically significant (all P < .01). There were more cases of ascites and portal hypertensive gastropathy after PTVE than after PTVE/PSE (P < .05). Survival rates at 6, 12, and 24 months in the PTVE/PSE group were 100%, 96.8%, and 96.8%, compared with 94.1%, 88.2%, and 82.4%, respectively, in the PTVE group. There were significant differences in peripheral blood cell counts and hemoglobin levels between the PTVE/PSE and PTVE groups at all observed time points (all P < .01).

CONCLUSIONS

PTVE/PSE not only has long-term efficacy in alleviating hypersplenism, but decreases recurrent bleeding and maintains hepatic reserve in patients with cirrhosis and esophagogastric variceal massive hemorrhage unable to undergo other procedures.

Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches.

Technical and clinical outcome of transjugular intrahepatic portosystemic stent shunt: bare metal stents (BMS) versus viatorr stent-grafts (VSG)

PURPOSE

To compare retrospectively angiographical and clinical results in patients undergoing transjugular intrahepatic portosystemic stent-shunt (TIPS) using BMS or VSG.

MATERIALS AND METHODS

From February 2001 to January 2010, 245 patients underwent TIPS. From those, 174 patients matched the inclusion criteria with elective procedures and institutional follow-up. Group (I) consisted of 116 patients (mean age, 57.0±11.1 years) with BMS. Group (II) consisted of 58 patients with VSG (mean age, 53.5±16.1 years). Angiographic and clinical controls were scheduled at 3, 6 and 12 months, followed by clinical controls every 6 months. Primary study goals included hemodynamic success, shunt patency as well as time to and number of revisions. Secondary study goals included clinical success.

RESULTS

Hemodynamic success was 92.2% in I and 91.4% in II (n.s.). Primary patency was significantly higher in II compared to I (53.8% after 440.4±474.5 days versus 45.8% after 340.1±413.8 days; p<0.05). The first TIPS revision was performed significantly later in II compared to I (288.3±334.7 days versus 180.1±307.0 days; p<0.05). In the first angiographic control, a portosystemic pressure gradient ≥15 mmHg was present in 73.9% in I and in 39.4% in II (p<0.05). Clinical success was 73.7-86.2% after 466.3±670.1 days in I and 85.7-90.5% after 617.5±642.7 days in II (n.s.). Hepatic encephalopathy was 37.5% in I and 36.5% in II (n.s.).

CONCLUSION

VSG increased primary shunt patency as well as decreased time to and number of TIPS revisions. There was a trend of higher clinical success in VSG without increased hepatic encephalopathy.

Factors predicting survival after transjugular intrahepatic portosystemic shunt creation: 15 years' experience from a single tertiary medical center

PURPOSE

This retrospective analysis was conducted to identify factors predictive of survival after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

Patients who underwent TIPS creation between January 1991 and December 2005 at a tertiary-care center were identified. Log-rank tests were used to compare the cumulative survival functions among groups of patients who underwent TIPS creation for various indications. Thirty-day mortality after TIPS creation was examined by logistic regression. Cox proportional-hazards analyses were performed to analyze the cumulative 90-day and 1-year survival. Selected variables such as creatinine, bilirubin, and International Normalized Ratio (INR) were assessed with respect to survival.

RESULTS

The study included 352 patients, of whom 229 (65.1%) were male. The mean age at the time of TIPS creation was 53.6 years (range, 21-82 y). A Model for End-stage Liver Disease (MELD) score greater than 15 was significantly associated with poor survival (P < .05) at 30 days, 90 days, and 1 year after TIPS creation. Independently, a serum total bilirubin level greater than 2.5 mg/dL, an INR greater than 1.4 (P < .05), and a serum creatinine level greater than 1.2 mg/dL were predictive of poor survival. Finally, age greater than 70 years was associated with poor survival at 90 days and 1 year after TIPS creation (P < .05).

CONCLUSION

The choice to create a TIPS in individuals whose MELD score is greater than 15 and/or whose age is greater than 70 years should involve a careful consideration of risk/benefit ratio, taking into account the finding that such patients have significantly poorer survival after TIPS creation.

Is sonographic surveillance of polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts (TIPS) necessary? A single centre experience comparing both types of stents

AIM

To investigate whether sonographic (US) surveillance of polytetrafluoroethylene covered transjugular intrahepatic portosystemic shunts (TIPS) is necessary.

MATERIALS AND METHODS

We identified 128 patients who underwent TIPS for complications of portal hypertension between January 2001 and December 2005 at a large tertiary centre. Procedural data were retrospectively analysed. US surveillance of the TIPS was performed at baseline with scheduled follow-up or whenever shunt dysfunction was suspected. Clinical and radiology reports were compared to assess US surveillance of the TIPS.

RESULTS

Four hundred and twenty-six US studies were performed, with a median of three per patient (range 1-5). The median follow-up period was 378 days (range 1-1749 days). Twenty-three patients (18%) had baseline US studies performed only whereas 105 (82%) also had follow-up studies. Forty-one (32%) of 128 patients [32 (78%) Wallstent, nine (22%) Viatorr] had Doppler ultrasound abnormalities noted. Venography was performed in all 41 patients. Abnormal venography and elevated hepatic venous pressure gradient (HVPG) was seen in 34 (82.9%) of the 41 patients [29 (85.3%) Wallstent, five (14.7%) Viatorr]. Among the 34 patients, 17 (50%) [13 (76.5%) Wallstent, four (23.5%) Viatorr] had venographic abnormalities noted at the hepatic venous end accompanied by increased HVPG. All four of the Viatorr patients had minor narrowing at the hepatic venous end and HVPG measurements that ranged 3-4 mm Hg above 12 mm Hg.

CONCLUSION

Considering the improved patency of covered stents in TIPS, US surveillance may be superfluous after the baseline study.

Diagnosis and management of primary aortoenteric fistulas--experience learned from eighteen patients

OBJECTIVE

Misdiagnosis of primary aortoenteric fistula (PAEF) frequently occurs in clinical practice owing to the rarity of this condition. Herein we present the experience of diagnosis and management for PAEF.

METHODS

Eighteen patients with PAEF at 2 medical centers in China were reviewed. The clinical data, diagnostic procedures, treatment options, and patient outcomes were evaluated.

RESULTS

The fistulas were located at esophagus (5), duodenum (8), jejunum (3), ileum (1), and transverse colon (1). The etiologies include atherosclerotic aneurysms and foreign body. Typical abdominal triad (pain, upper GI bleeding, and abdominal pulsating mass) was found in 27.8% of patients, and Chiari's triad (mid-thoracic pain, sentinel hemorrhage, and massive bleeding after a symptom-free interval) was present in 3 of 5 cases with thoracic aortoesophageal fistulas. All patients had an average of 3.6 (1-9) episodes of gastrointestinal bleeding. The interval between the first sentinel hemorrhage and ultimate exsanguination ranged from 5 hours to 5 months (median, 4 days). Six patients (33.3%) were diagnosed or suggested by diagnostic tools including endoscopy, computerized tomography, and arteriography. Others were diagnosed by surgical exploration (7) and autopsy (5). One to 5 rounds (mean 1.8) of misdiagnosis occurred in 15 patients. Six patients recovered from surgery and remained well during a 36-month follow-up. The surgical options used included in situ replacement with vascular graft (3), aneurysmorraphy and closure of fistula (1), and endovascular stenting (2).

CONCLUSIONS

A high index of suspicion is necessary for correct diagnosis and prompt management of PAEF, especially in patients with aortoiliac aneurysms presenting with gastrointestinal bleeding. In situ graft replacement and endovascular stent-graft may be the preferred therapeutic options.

Diagnosis and therapy of esophageal vascular disorders

PURPOSE OF REVIEW

The most relevant studies concerning the diagnosis of esophageal varices, primary and secondary prophylaxis and treatment of variceal bleeding published in the last year are reported.

RECENT FINDINGS

The specific areas reviewed are those that refer to studies on the noninvasive or minimally invasive diagnosis of the presence of esophageal varices, the prevention of the formation and of the progression of varices from small to large, the prevention of the first variceal haemorrhage, the treatment of the acute bleeding episode, and the prevention of rebleeding.

SUMMARY

Relevant studies are reviewed regarding the validation of noninvasive indices for the presence of varices, the use of the esophageal videocapsule to diagnose varices, the comparison of methods to prevent the first variceal haemorrhage, the use of the hepatic vein pressure measurement to monitor the haemodynamic response to beta-blockers, the long-term protection from bleeding by beta-blockers, the use of a double dose of somatostatin to control bleeding, the evaluation of the best endoscopic method to treat variceal bleeding in addition to vasoactive drugs, and the identification of prognostic factors for early and late mortality after a variceal bleed.